Abstract
Background: Type 2 diabetes is a progressive condition where beta cell function deteriorates over time. Insulin injection therapy is often required 5-10 years post-diagnosis, but many people who require insulin delay starting it. There are currently education groups available for people with type 2 diabetes starting insulin, but these have been designed to support safe insulin administration and do not consider psychological problems or barriers, such as fear of hypoglycaemia or weight gain. There is evidence to support the effectiveness of group education and psychological interventions for people with type 2 diabetes, but so far insulin group education has not been evaluated. Research is needed to develop psychologically informed insulin group education which incorporates elements of psychological interventions for people with type 2 diabetes, to understand how psychological factors such as depressive symptoms, diabetes distress and insulin beliefs affect initiation of insulin and to understand from people who have attended insulin education their views of it and how it could be improved.Methods: Study 1 is a systematic review and meta-analysis to assess the effectiveness of behaviour change techniques in psychological interventions to improve HbA1c for people with type 2 diabetes. Study 2 used qualitative semi-structured interviews to determine the views of people with type 2 diabetes in south London who had attended insulin education, regarding barriers to insulin self-management, views on current insulin group education, and suggestions for additional support to aid insulin self-management. Study 3 is an 8-year medical records follow-up of an existing National Institute of Health Research funded south London Diabetes cohort (SOUL-D) of n=1735 people with type 2 diabetes. It examined whether psychological factors (depressive symptoms, diabetes distress and insulin beliefs) around diagnosis delay time to insulin initiation and insulin requiring status in people with type 2 diabetes. Finally, study 4 combined evidence from studies 1-3 to inform the manual development of a psychological intervention called Diabetes Insulin Management Education (DIME). The DIME intervention aimed to optimise insulin initiation in people with type 2 diabetes. Initial testing of DIME took place with groups of people with type 2 diabetes who initiated insulin (from south London). Study 5 was a qualitative (one-to-on exit interviews) and quantitative (case study of interviewees) evaluation of the DIME pilot sessions to determine acceptability (study 5).
Results: In study 1, the most commonly used behaviour change techniques in psychological interventions which were associated with improved HbA1c included ‘social support’, ‘feedback and monitoring’, and ‘goal setting’. Study 2 revealed positive experiences of insulin group education for people with type 2 diabetes was linked to sharing experiences with other people starting insulin, reassurance from healthcare professionals, appropriate supportive materials, and skill of the facilitator to address insulin concerns and manage group dynamics. In study 3, in a cox regression, depressive symptoms at type 2 diabetes diagnosis (HR=1.06, 95% CI=1.02-1.10, p=0.005) were the only psychological factor which predicted significantly shorter time insulin initiation, controlling for other baseline confounding variables. Following initial testing of DIME, positive feedback included: alleviation of fears and anxieties around insulin; positive communication style; finding common ground with people in the group; and group dynamics were managed well.
Conclusions: Psychological interventions as well as behaviour change technique categories are beneficial to improving HbA1c. A group environment and facilitator skill play a key role in positive impact of insulin education. Appropriate psychological techniques to address depressive symptoms should be taken into consideration in development of insulin initiation education. Initial testing of a psychological intervention to optimise insulin initiation provides positive feedback and improvement in HbA1c and should be tested in a randomised controlled trial to determine effectiveness.
| Date of Award | 1 Jul 2020 |
|---|---|
| Original language | English |
| Awarding Institution |
|
| Supervisor | Kirsty Winkley (Supervisor) & Khalida Ismail (Supervisor) |